Editing Medicaid (section)

=== Expansion under the Affordable Care Act ===

[[File:Medicaid expansion map of US. Affordable Care Act.svg|thumb|upright=1.35|[[Medicaid coverage gap#Medicaid expansion|ACA Medicaid expansion]] by state:<ref name="KFF-Medicaid">{{cite web |title=Status of State Medicaid Expansion Decisions: Interactive Map |date=December 2023 |url=https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map |publisher=[[Kaiser Family Foundation|KFF]]. Map is updated as changes occur. Click on states for details.}}</ref>
{{legend|#2b83ba|Not adopted}}
{{legend|#E5B89B|Implemented}}]]
[[File:Uninsured Rate Comparing Medicaid Expansion States vs. Non Expansion.png|thumb|upright=1.35|States that expanded Medicaid under ACA had a lower uninsured rate in 2018 at various income levels.<ref name="Census_2018">{{Cite web |url=https://www.census.gov/library/publications/2019/demo/p60-267.html|title=Health Insurance Coverage in the United States: 2018|date=September 10, 2019}}</ref>]]

The [[Affordable Care Act]] (ACA), passed in 2010, substantially expanded the Medicaid program. Before the law was passed, some states did not allow able-bodied adults to participate in Medicaid, and many set income eligibility far below the Federal poverty level. Under the provisions of the law, any state that participated in Medicaid would need to expand coverage to include anyone earning up to 138% of the Federal poverty level beginning in 2014. The costs of the newly covered population would initially be covered in full by the Federal government, although states would need to pay for 10% of those costs by 2020.<ref>{{cite news |author=HHS Press Office |date=March 29, 2013 |title=HHS finalizes rule guaranteeing 100 percent funding for new Medicaid beneficiaries |location=Washington, DC |publisher=U.S. Department of Health & Human Services |url=https://www.hhs.gov/news/press/2013pres/03/20130329a.html |access-date=April 23, 2013 |quote=effective January 1, 2014, the federal government will pay 100 percent of defined cost of certain newly eligible adult Medicaid beneficiaries. These payments will be in effect through 2016, phasing down to a permanent 90 percent matching rate by 2020. |archive-date=April 8, 2013 |archive-url=https://web.archive.org/web/20130408193512/http://www.hhs.gov/news/press/2013pres/03/20130329a.html |url-status=dead }}<br />{{cite journal |author=Centers for Medicare & Medicaid Services |date=April 2, 2013 |title=Medicaid program: Increased federal medical assistance percentage changes under the Affordable Care Act of 2010: Final rule |journal=Federal Register |volume=78 |issue=63 |pages=19917–19947 |quote=(A) 100 percent, for calendar quarters in calendar years (CYs) 2014 through 2016; (B) 95 percent, for calendar quarters in CY 2017; (C) 94 percent, for calendar quarters in CY 2018; (D) 93 percent, for calendar quarters in CY 2019; (E) 90 percent, for calendar quarters in CY 2020 and all subsequent calendar years.}}</ref><ref>{{cite web |title=HHS finalizes rule guaranteeing 100 percent funding for new medicaid beneficiaries |url=https://www.thelundreport.org/keywords/department-health-and-human-services |website=The Lund Report |access-date=23 June 2022 |archive-url=https://web.archive.org/web/20201030161511/https://www.thelundreport.org/content/hhs-finalizes-rule-guaranteeing-100-percent-funding-new-medicaid-beneficiaries |archive-date=30 October 2020 |location=Portland OR |date=29 March 2013 |agency=Department of Health and Human Services}}</ref><ref>{{Cite web|url=https://archive-it.org/collections/3926?fc=meta_Date:2013|title=Archive-It - News Releases|website=archive-it.org}}</ref><ref>{{Cite web |url=https://www.cbpp.org/research/how-health-reforms-medicaid-expansion-will-impact-state-budgets |title=How Health Reform's Medicaid Expansion Will Impact State Budgets |date=July 11, 2012 |website=Center on Budget and Policy Priorities}}</ref>

However, in 2012, the Supreme Court held in ''[[National Federation of Independent Business v. Sebelius]]'' that withdrawing all Medicaid funding from states that refused to expand eligibility was unconstitutionally coercive. States could choose to maintain pre-existing levels of Medicaid funding and eligibility, and some did; over half the national uninsured population lives in those states.<ref name="NYT52413">{{cite news |title=States' Policies on Health Care Exclude Some of the Poorest |url=https://www.nytimes.com/2013/05/25/us/states-policies-on-health-care-exclude-poorest.html |newspaper=The New York Times |date=May 24, 2013 |author=Robert Pear |access-date=May 25, 2013 |quote=In most cases, [Sandy Praeger, Insurance Commissioner of Kansas], said adults with incomes from 32 percent to 100 percent of the poverty level ($6,250 to $19,530 for a family of three) "will have no assistance".}}</ref> As of March 2023, 40 states have accepted the [[Affordable Care Act]] Medicaid extension, as has the [[Washington, D.C.|District of Columbia]], which has its own Medicaid program; 10 states have not.<ref name="KFF_States">{{Cite web |url=http://kff.org/health-reform/slide/current-status-of-the-medicaid-expansion-decision/ |title=Current Status of State Medicaid Expansion Decisions |access-date=February 26, 2023 |archive-date=November 27, 2016 |archive-url=https://web.archive.org/web/20161127103011/http://kff.org/health-reform/slide/current-status-of-the-medicaid-expansion-decision/ |url-status=dead }}</ref> Among adults aged 18 to 64, states that expanded Medicaid had an uninsured rate of 7.3% in the first quarter of 2016, while non-expansion states had a 14.1% uninsured rate.<ref name="Urban_Q12016">{{Cite web |url=http://hrms.urban.org/briefs/health-insurance-coverage-ACA-March-2016.html |title=Health Reform Monitoring Survey |access-date=December 5, 2016 |archive-date=November 21, 2016 |archive-url=https://web.archive.org/web/20161121020226/http://hrms.urban.org/briefs/health-insurance-coverage-ACA-March-2016.html |url-status=dead }}</ref>

The [[Centers for Medicare and Medicaid Services]] (CMS) estimated that the cost of expansion was $6,366 per person for 2015, about 49 percent above previous estimates. An estimated 9 to 10 million people had gained Medicaid coverage, mostly low-income adults.<ref name=":10">{{Cite web|url=https://www.elderlawanswers.com/medicaids-power-to-recoup-benefits-paid-estate-recovery-and-liens-12018|title=Medicaid's Power to Recoup Benefits Paid: Estate Recovery and Liens|website=ElderLawAnswers|date=December 13, 2012|language=en|access-date=2019-08-07}}</ref> The Kaiser Family Foundation estimated in October 2015 that 3.1 million additional people were not covered in states that rejected the Medicaid expansion.<ref>{{Cite web |url=http://kff.org/disparities-policy/issue-brief/the-impact-of-the-coverage-gap-in-states-not-expanding-medicaid-by-race-and-ethnicity/ |title=The Impact of the Coverage Gap for Adultsin States not Expanding Medicaid |date=October 26, 2015}}</ref>

In some states that chose not to expand Medicaid, income eligibility thresholds are significantly below 133% of the poverty line.<ref name="Kliff, Sarah">{{cite news |url=https://www.washingtonpost.com/blogs/ezra-klein/wp/2012/07/05/what-happens-if-a-state-opts-out-of-medicaid-in-one-chart |title=What Happens if a State Opts Out of Medicaid, in One Chart |author=Kliff, Sarah |date=July 5, 2012 |newspaper=The Washington Post |access-date=July 15, 2012 |archive-date=July 13, 2012 |archive-url=https://web.archive.org/web/20120713153024/http://www.washingtonpost.com/blogs/ezra-klein/wp/2012/07/05/what-happens-if-a-state-opts-out-of-medicaid-in-one-chart/ |url-status=dead }}</ref> Some of these states do not make Medicaid available to non-pregnant adults without disabilities or dependent children, no matter their income. Because subsidies on commercial insurance plans are not available to such individuals, most have few options for obtaining any medical insurance.<ref>{{cite web |title=Analyzing the Impact of State Medicaid Expansion Decisions |url=http://kff.org/medicaid/issue-brief/analyzing-the-impact-of-state-medicaid-expansion-decisions/ |publisher=Kaiser Family Foundation |date=July 17, 2013}}</ref><ref name="Families USA">{{cite web |url=http://www.familiesusa.org/assets/pdfs/health-reform/Enrollment-Policy-Provisions.pdf |title=Enrollment Policy Provisions in the Patient Protection and Affordable Care Act |publisher=Families USA |access-date=April 1, 2012 |archive-date=March 31, 2012 |archive-url=https://web.archive.org/web/20120331052051/http://www.familiesusa.org/assets/pdfs/health-reform/Enrollment-Policy-Provisions.pdf |url-status=dead }}</ref> For example, in [[Kansas]], where only non-disabled adults with children and with an income below 32% of the poverty line were eligible for Medicaid, those with incomes from 32% to 100% of the poverty level ($6,250 to $19,530 for a family of three) were ineligible for both Medicaid and federal subsidies to buy insurance.<ref name="NYT52413" />

Studies of the impact of Medicaid expansion rejections calculated that up to 6.4 million people would have too much income for Medicaid but not qualify for exchange subsidies.<ref>{{cite magazine |title=We Don't Know Everything About Obamacare. But We Know Who's Trying to Sabotage It |first=Jonathan |last=Cohn |magazine=The New Republic |date=July 19, 2013 |url=https://newrepublic.com/article/113947/obamacare-implementation-and-role-state-officials}}</ref> Several states argued that they could not afford the 10% contribution in 2020.<ref name="CNNMedicaid">{{cite news |url=https://money.cnn.com/2013/07/01/news/economy/medicaid-expansion-states/index.html |title=States forgo billions by opting out of Medicaid expansion |author=Tami Luhby |publisher=CNN |date=July 1, 2013}}</ref><ref name="Medicaiddeal">{{cite web |url=https://www.usnews.com/debate-club/is-medicaid-expansion-good-for-the-states |title=Is Medicaid Expansion Good for the States? |work=U.S. News & World Report |date=n.d.}}</ref> Some studies suggested that rejecting the expansion would cost more due to increased spending on uncompensated [[emergency care]] that otherwise would have been partially paid for by Medicaid coverage.<ref>{{cite news |title=Wonkbook: The terrible deal for states rejecting Medicaid |url=https://www.washingtonpost.com/news/wonk/wp/2013/06/04/wonkbook-the-terrible-deal-for-states-rejecting-medicaid/?variant=116ae929826d1fd3&variant=116ae929826d1fd3 |date=June 4, 2013 |newspaper=The Washington Post |author1=Evan Soltas}}</ref>

A 2016 study found that residents of [[Kentucky]] and [[Arkansas]], which both expanded Medicaid, were more likely to receive health care services and less likely to incur emergency room costs or have trouble paying their medical bills. Residents of [[Texas]], which did not accept the Medicaid expansion, did not see a similar improvement during the same period.<ref>{{Cite web |url=https://www.newscientist.com/article/2100311-obamacare-has-already-improved-health-of-low-income-americans |title=Obamacare has already improved health of low-income Americans |last=Rutkin |first=Aviva |language=en-US |access-date=August 15, 2016}}</ref> Kentucky opted for increased managed care, while Arkansas subsidized private insurance. Later, Arkansas and Kentucky governors proposed reducing or modifying their programs. From 2013 to 2015, the uninsured rate dropped from 42% to 14% in Arkansas and from 40% to 9% in Kentucky, compared with 39% to 32% in Texas.<ref>{{Cite web |url=https://www.hsph.harvard.edu/news/press-releases/medicaid-expansion-aca-lbetter-health-care-improved-health-low-income-adults/ |title=Medicaid expansion under ACA linked with better health care, improved health for low-income adults {{!}} News {{!}} Harvard T.H. Chan School of Public Health|website=www.hsph.harvard.edu|access-date=August 30, 2016|date=August 8, 2016}}</ref>

A 2016 [[United States Department of Health and Human Services|DHHS]] study found that states that expanded Medicaid had lower premiums on exchange policies because they had fewer low-income enrollees, whose health, on average, is worse than that of people with higher income.<ref>{{Cite news |url=https://www.nytimes.com/2016/08/26/upshot/how-expanding-medicaid-may-lower-insurance-premiums.html |title=How Expanding Medicaid Can Lower Insurance Premiums for All |last=Sanger-katz |first=Margot |date=August 25, 2016 |newspaper=The New York Times |issn=0362-4331 |access-date=September 4, 2016}}</ref>

The [[United States Census Bureau|Census Bureau]] reported in September 2019 that states that expanded Medicaid under ACA had considerably lower uninsured rates than states that did not. For example, for adults between 100% and 399% of poverty level, the uninsured rate in 2018 was 12.7% in expansion states and 21.2% in non-expansion states. Of the 14 states with uninsured rates of 10% or greater, 11 had not expanded Medicaid.<ref name="Census_2018" /> A July 2019 study by the National Bureau of Economic Research (NBER) indicated that states enacting Medicaid expansion exhibited statistically significant reductions in mortality rates.<ref>{{Cite book|last1=Miller|first1=Sarah|last2=Altekruse|first2=Sean|last3=Johnson|first3=Norman|last4=Wherry|first4=Laura|date=July 2019|title=Medicaid and Mortality: New Evidence from Linked Survey and Administrative Data|location=Cambridge, MA|publisher=National Bureau of Economic Research|series=NBER Working Paper No. 26081|doi=10.3386/w26081|s2cid=164463149|url=http://www.nber.org/papers/w26081.pdf }}</ref>

The ACA was structured with the assumption that Medicaid would cover anyone making less than 133% of the Federal poverty level throughout the United States; as a result, premium tax credits are only available to individuals buying private health insurance through [[Health insurance marketplace|exchanges]] if they make more than that amount. This has given rise to the so-called [[Medicaid coverage gap]] in states that have not expanded Medicaid: there are people whose income is too high to qualify for Medicaid in those states, but too low to receive assistance in paying for private health insurance, which is therefore unaffordable to them.<ref>{{cite news | url=https://psmag.com/social-justice/the-medicaid-coverage-gap-persists | title=The Medicaid Coverage Gap Persists | work=Pacific Standard | date=26 January 2016 | accessdate=7 March 2016 | author=Gunn, Dwyer}}</ref>